Hepatitis C mortality in U.S. outstrips mortality from other notifiable infectious causes

by Michael Smith Michael Smith North American Correspondent, MedPage Today
October 13, 2015

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Despite dramatic improvements in treatment, mortality from hepatitis C continues to rise in the U.S.

Note that the study suggests that new and highly effective drugs may not be used as widely as they could be, and that payers are prioritizing the sickest patients, while hundreds of thousands of people wait for treatment.

SAN DIEGO -- Despite dramatic improvements in treatment, mortality from hepatitis C (HCV) continues to rise in the U.S., a researcher said here.

In fact, annual HCV-associated deaths have surpassed the total number of deaths linked to the other 60 nationally notifiable infectious diseases combined, according to Scott Holmberg, MD,MPH, of the CDC's Division of Viral Hepatitis in Atlanta.

And the numbers are almost certainly a marked underestimate, Holmberg said, since, in a well-characterized cohort of HCV patients, only about one in five patients who died had the disease listed on the death certificate.

The finding should not come as a surprise to those in the field, commented Paul Griffiths, MD, DSc, of University College London, who was not part of the study but who moderated the session at which it was presented.

"People should already be aware of the issue," he told MedPage Today, "but it's good to see the data."

The main problem, he said, is that new and highly effective drugs are not being "deployed" as widely as they could be, largely because of cost. "It is usually better to treat someone early in the disease," he said but that's not what's happening.

Instead, because of the cost, payers are prioritizing the sickest patients, while hundreds of thousands of people wait for treatment, including many who are not yet aware they have chronic HCV.

Holmberg drew a distinction between "two epidemics" -- the estimated 3.2 million people in the U.S. with chronic HCV and the emerging epidemic of acute disease among rural injection drug users.

It's the chronic patients who pose the biggest problem, he said, simply because there are many more of them. To see exactly how big the problem is, he and colleagues turned to national death certificate records and the prospective longitudinal Chronic Hepatitis Cohort Study (CHeCS).

An earlier analysis of death certificates revealed that HCV deaths outstripped HIV deaths starting in 2007, Holmberg noted. To amplify that result, his group analyzed ICD-10 codes in death certificates from 2003 through 2013, looking for HCV and 60 other notifiable infectious diseases listed as "underlying conditions."

They calculated mortality rates by dividing annual deaths associated with each condition by the census population for that year.

In 2003, the other 60 conditions combined were cited in about 25,000 deaths, compared with about 11,000 for HCV. But the curves were going in different directions and crossed in 2011, Holmberg said.

Griffiths noted that HCV, unlike many chronic diseases, can be cured since the virus can only persists if it is allowed to replicate -- something that the new drugs block.

To get a sense of how well death certificates capture the HCV mortality picture, the authors turned to the CHeCS data from 2007 through 2013, including information on more than 12,000 patients with some 54,544 person-years of follow-up.

They found that the death rate in the cohort had doubled, from 2.4 per 100 person-years in 2007 to 5.4 per 100 person-years in 2013, for a total of 1,600 deaths among the HCV patients.

Importantly, he said, only 19% of the death certificates of those people mentioned HCV, despite pre-mortem evidence of serious liver disease in more than 75% of them. If that rate can be extrapolated to the national death certificates, it would mean that HCV was associated with between 75,000 and 100,000 deaths in 2013, instead of about 19,300.

A key issue is that the "continuum of care" for HCV includes several barriers to cure, including cost of medications, doctors who think HCV is a "benign" disease, patients who often have more pressing life issues, and political attitudes, he said.

The study was supported by the CDC.

Holmberg and co-authors disclosed no relevant relationships with industry.

Griffiths disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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